Marc Darrow, MD, JD. Joint Rehab Los Angeles
In many people we have seen at our Los Angeles spine and joint clinic, they have been misdiagnosed with sciatica. They were also given treatment and surgical recommendations for sciatica that were destined not to work. The problem for many, may be the diagnosis.
Let’s bring in other opinions.
A July 2020 paper in one of the world’s most prestigious medical journals the Lancet (1) discusses the problems of diagnosis and treatment of sciatica. The authors noted the same issues we see.
“Management of sciatica can be suboptimal and shows large variation in clinical practice. In general, we only have limited knowledge about the diagnosis of sciatica, the value of diagnostic interventions, the natural and clinical course of disease, predictors of outcome, and the efficacy of most therapeutic interventions. Compared to the amount of research on non-specific low back pain, research activities focused on sciatica are scarce.”
Because of this confusion at leading medical institutes and research centers as to how to diagnose and treat sciatica, when someone tell us they have sciatica and nothing has helped them, we explore their medical history a little further to see if they have a true sciatica that is difficult to fix without surgery or a pseudo-sciatica that can be very responsive to conservative care and regenerative medicine treatments.
Sciatica medication: “Most participants found medication ineffective and reported significant side-effects.”
We see many patients on pain medications who are seeing us because their pain meds are not helping and they are seeking alternative non-surgical options for their sciatic pain.
A June 2021 study (2) noted that for sciatica, medication is routinely the first line of management. It also noted to doctors that it is important to describe patients experiences of taking medication for sciatica, the reasons for commencing and reasons for cessation, the effects of the medication in symptom management and any other potential positive or deleterious effects.
Why? Because they further noted that in a survey of the patients prescribed medications, “Most participants found medication ineffective and reported significant side-effects.” The recommendation to the doctors? “Clinicians should be cognizant of the fears that patients hold in terms of the cause and severity of sciatica, as well as fears of prescribed medication.”
Exercise, physical therapy, epidurals, cortisone and spinal manipulation for sciatica. When they work and when they don’t.
In a May 2025 study (3) researchers investigated the comparative effectiveness of non-surgical interventions for adults with chronic sciatica (sciatica for 3 months or longer). The researchers looked at treatment outcomes for leg pain intensity and physical function at short-, medium-, and long-term follow-up in previously published studies. In computing the data, the researchers found:
- At short-term, spinal manipulative therapy, exercise + neural mobilization, and soft tissue anesthetic injections showed the largest reductions in leg pain intensity versus placebo (all based on very low confidence evidence).
- Epidural magnesium injections improved physical function at short-term
- Long-term reductions in leg pain occurred with epidural steroid + ketamine injections and epidural injections + physical therapy.
However, the researchers stress the evidence is very uncertain regarding the effectiveness of non-surgical interventions in patients with chronic sciatica. The studies they reviewed my have been subject to bias nd were of smaller sample size. They conclude: “Currently, no high-quality evidence confirms the superior effectiveness of any non-surgical intervention for patients with chronic sciatica. While some treatments may provide short-term leg pain relief, the very low confidence of the evidence highlights the need for rigorous and large-scale trials to better guide clinical decision-making.”
Epidural steroid injection for sciatica, short-term benefit and lack of long-term effectiveness.
A March 2025 study (4) compared data from 72 studies on the effectiveness of epidural steroid injection with other manipulations in treating sciatica. They found epidural steroid injection has better results to other conservative treatment modalities for sciatica; However surgery seems to have more immediate effect and better long term outcome.
However, they noted the conservative treatment comparisons were the usual care for sciatica involves conservative measures such as “adequate pain relief, nonsteroidal anti-inflammatory drugs, and lifestyle modifications. These modifications include bed rest, weight management, physical therapy, and exercise. If the previous measures fail to alleviate the symptoms, physicians may recommend epidural steroid.” Further, “it is essential to note that an epidural steroid injection does not directly cause regression of a herniated nucleus pulposus. Moreover, there are important variations in epidural steroid injection, including the guiding technique, drug used, dosage, and concentration. This has led to considerable controversy regarding the role of epidural steroid injection in treating patients with sciatica.”
Physical therapy for sciatica
Many people we see have limited success with physical therapy for their sciatica. This view is also shared by a December 2022 study from the United Kingdom (5) which assessed the effectiveness of physical therapy versus control interventions in people with sciatica. In reviewing data from 2699 patients included in 18 previously studies, the researchers found physical therapy did not offer any more pain alleviation or improved disability than the control interventions.
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Other articles:
References
1 Koes BW. Improving the management of sciatica. The Lancet Rheumatology. 2020 Jul 1;2(7):e372-3.
2 Reddington M, Baxter S, Walters SJ. A qualitative exploration of patient experiences of medication for sciatica. Musculoskeletal Science and Practice. 2021 Jun 21:102419.
3 Zhu Z, Schouten T, Strijkers R, Koes B, Gerger H, Chiarotto A. Effectiveness of non-surgical interventions for patients with chronic sciatica: a systematic review with network meta-analysis. The Journal of Pain. 2025 May 13:105431.
4 Brotis AG, Spiliotopoulos T, Kalogeras A, Fountas KN, Demetriades AK. Epidural steroid injections in lumbar disc herniation-Evidence synthesis from 72 randomised controlled trials (RCTs) and a total of 7,701 patients. Brain and Spine. 2025 Mar 13:104216.
5 Dove L, Jones G, Kelsey LA, Cairns MC, Schmid AB. How effective are physiotherapy interventions in treating people with sciatica? A systematic review and meta-analysis. European Spine Journal. 2023 Feb;32(2):517-33.